BACKGROUND:Pulsed-field ablation (PFA) has transformed atrial fibrillation (AF) ablation, but how the early patient experience compares with thermal techniques remains unclear. This study aimed to assess patient-reported outcome measures (PROMs) in the first 3 months after PFA or thermal AF ablation, using a novel smartphone-based application. METHODS:Patients undergoing first-time pulmonary vein isolation prospectively completed the Cardiac Ablation Recovery Evaluation (CARE) symptom questionnaire at five timepoints: baseline, day 1, day 7, day 30, and day 90. Symptoms were rated on a 7-point Likert scale (0 = not at all; 6 = extremely). Patients also completed the Atrial Fibrillation Effect on QualiTy-of-life (AFEQT) questionnaire at baseline and day 90. RESULTS:Two hundred and two patients were included (pentaspline PFA: 66; radiofrequency: 64; cryoballoon: 72), with similar baseline demographics between groups, except for a lower prevalence of paroxysmal AF in the PFA group. Engagement with the smartphone-based platform was high, with a 94.7% completion rate. Median AFEQT scores improved from 64 (47-82) at baseline to 86 (72-95) at day 90 (p < 0.001), with no significant differences between modalities (p = 0.841). However, CARE detected differences in early symptom experience: chest pain was lowest with PFA at day 1 (median: PFA, 1 [0-2]; radiofrequency, 2 [1-2]; cryoballoon, 2 [1-2]; p < 0.001), and remained lower than cryoballoon at day 7 (p = 0.019), with differences resolving by day 30. Moderate-to-severe chest pain (score ≥ 3) occurred in only 12.3% of PFA patients at day 1, compared with 21.2% cryoballoon and 26.2% radiofrequency patients (p < 0.001). Palpitations at day 1 were less frequent with PFA than radiofrequency (p = 0.040). Groin discomfort was lower with radiofrequency than PFA or cryoballoon at day 1 (p = 0.006) and day 7 (p < 0.001), likely reflecting a smaller sheath size. CONCLUSIONS:PFA was associated with a modest and transient reduction in early post-procedural chest pain compared with thermal ablation. Smartphone application-based PROMs collection using the CARE questionnaire was feasible, enabling structured assessment of symptom burden across multiple recovery timepoints.

BACKGROUND:Reliable hemostasis is essential to minimize femoral venous access site complications after transcatheter cardiovascular procedures, particularly atrial fibrillation (AF) ablation, which require large-bore sheath insertion and systemic heparinization. A figure-of-8 suture secured with a 3-way tap (Fo8TAP) offers a simple and low-cost alternative to manual compression (MC). OBJECTIVES:The HARNESS (Haemostasis After Venous Access in Atrial Fibrillation Catheter Ablation) randomized controlled trial evaluated the efficacy of Fo8TAP and its impact on post-procedural bed rest duration. METHODS:Patients undergoing AF ablation via unilateral femoral venous access were randomized 1:1:1 to: 1) MC with 4-hour bed rest (MC-4), 2) Fo8TAP with 4-hour bed rest (TAP-4), and 3) Fo8TAP with 2-hour bed rest (TAP-2). The primary endpoint of any access site complication before hospital discharge was assessed for superiority (TAP-4 vs MC-4) and noninferiority (TAP-2 vs TAP-4). Bleeding was graded from 1 (minor) to 4 (life-threatening). Secondary endpoints included times to hemostasis, catheter laboratory exit, and mobilization. RESULTS:A total of 336 patients (median age 64 years, 34.2% female, median body mass index 28.9 kg/m2) were enrolled and randomized to MC-4 (n = 110), TAP-4 (n = 110), and TAP-2 (n = 116). The primary endpoint occurred in 16 patients (14.5%) in the TAP-4 group and 36 patients (32.7%) in the MC-4 group (P = 0.002 for superiority). In the TAP-2 group, the primary endpoint occurred in 36 (31.0%) patients (P = 0.156; which did not meet the prespecified noninferiority margin vs TAP-4). No major vascular complications occurred. Most events were grade 1 bleeding (85/92, 92.4%), with the remainder minor hematomas (7/92, 7.6%). Median time to hemostasis was significantly shorter with Fo8TAP (MC-4: 12 min; TAP-4 and TAP-2: 1 min; P < 0.001). Median time to catheter laboratory exit was shortest with Fo8TAP (MC-4: 16 min; TAP-4: 9 min; TAP-2: 8 min; P < 0.001). Median time to mobilization was shortest with TAP-2 (MC-4: 242 min; TAP-4: 241 min; TAP-2: 122 min; P < 0.001). CONCLUSIONS:After AF catheter ablation, Fo8TAP was superior to MC in lowering the incidence of access site complications and was associated with health care efficiencies. However, a 2-hour bed rest strategy failed to meet noninferiority criteria versus 4 hours. (Haemostasis After Venous Access in Atrial Fibrillation Catheter Ablation [HARNESS]; NCT06470555).

ABSTRACTIntroductionFreedom from recurrences of atrial tachyarrhythmia (ATA) is suboptimal after pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (PsAF). This sub‐analysis from the Cryo Global Registry sought to investigate predictors of ablation success after PVI using cryoballoon ablation (CBA) for PsAF.Methods and ResultsATA recurrence was defined as ≥ 30 s recurrence of atrial fibrillation, atrial flutter or atrial tachycardia after a 90‐day blanking period and through 12‐months. Univariate and multivariable Cox regression analysis (with ATA recurrence as an endpoint) was performed to identify CBA responders. PsAF patients (N = 882) were on average 63.9 ± 11.3 years old (69.2% male), and freedom from ATA recurrence was 79.7% (76.8%–82.2%). Longer elapsed time from PsAF diagnosis to ablation (hazard ratio [HR] 1.07 (95% confidence interval [CI]: 1.03–1.11); p = 0.002) and a larger number of previously failed antiarrhythmic drugs (HR 1.39 (95% CI: 1.13–1.70); p < 0.002) were shown to be independent predictors of ATA recurrence in a multivariate model which included 703 evaluated patients.ConclusionThese real‐world results provide important insights to guide referral of PsAF patients, including the benefits of earlier treatment via CBA.

Introduction:Cryoballoon ablation (CBA) is a well-established treatment for atrial fibrillation (AF). However, evidence on the impact of sex on outcome is sparse. This real-world analysis aims to describe outcome after CBA in both sexes. Methods:This registry is an ongoing, global evaluation of CBA procedures in standard-of-care practice. Females undergoing CBA were compared to males at baseline and 12-, and 24-months post-ablation. Serious procedure-related adverse event rate, rate of atrial arrhythmia (AA) recurrence, repeat ablation, hospitalization, cardioversion, and quality-of-life (QoL; EQ-5D-3l) were compared. Results:Of 3,089 patients with 12-month follow-up, 1,136 (36.8%) were female; and a subset of 1,099 patients (400 female) were followed through 24 months. Females presented with different comorbidities at baseline. The complication rate was low overall in females (3.9%) and males (2.7%, p = 0.07). At 24-month follow-up, the rate of AA recurrence was 25.0% in females and 22.1% in males and female sex was a predictor of AA recurrence (HR adj = 1.21, p = 0.047) and rehospitalizations (HR adj = 1.25, p = 0.03) in a propensity score adjusted analysis. In addition, females stayed in the hospital longer compared to males during the index ablation procedure (47.9% with 2 or more days in hospital vs. 39.3% in males, p < 0.01), as well as during the first hospital stay post-ablation (78.2% with 2 or more days in hospital vs. 60.2% in males, p < 0.01). QoL improved from baseline to 12 months in females (0.85 ± 0.15-0.90 ± 0.13) and males (0.91 ± 0.13-0.94 ± 0.11) and remained high at 24 months. Discussion:CBA performed according to standard-of-care practice was safe in both sexes. The efficacy of CBA is marginally lower in females, but 75% of females remained free from AA recurrence at 24-months and reported a meaningful improvement in QoL post ablation. Systematic Review Registration:https://clinicaltrials.gov/ct2/show/NCT02752737, The Cryo Global Registry (NCT02752737).

Patients with transposition of the great arteries (TGA) who undergo atrial switch procedures may develop symptomatic atrial arrhythmias necessitating ablation. We present a single-centre retrospective analysis of a novel approach using jugular access for catheter ablation in this unique patient population. A 5-year retrospective analysis was conducted on patients referred for atrial arrhythmia ablation following atrial switch procedures. Procedures were performed by experienced operators, and data on patient demographics, procedural characteristics, and outcomes were collected. Statistical analysis was performed to compare outcomes between jugular and femoral access groups. Jugular access (N = 9) and femoral access (N = 13) cohorts were comparable in age, gender distribution, and clinical characteristics. Procedural success rates were high in both groups, with no significant difference in recurrence rates. Jugular access demonstrated a comparatively safe profile compared to femoral access. The jugular approach offers a viable alternative to femoral access for atrial arrhythmia ablation in patients with atrial switch procedures. The trajectory from the internal jugular vein to the baffle is straightforward, reducing vascular complications. Success rates and procedural times were comparable, highlighting the feasibility and safety of the jugular approach. The option for rapid post-procedural mobilisation adds to its appeal. Atrial arrhythmia ablation with jugular access in patients with atrial switch procedures is safe and effective, providing an alternative in cases where femoral access may pose challenges. This approach warrants consideration in the management of atrial arrhythmias in this unique patient population.

Technological advances in atrial fibrillation (AF) ablation have improved procedural safety and patient outcomes over the past two decades. Whist novel technologies may offer the promise of improved outcomes with reduced complications, it is important to evaluate them against established therapies. Pulsed-field ablation (PFA) with a pentaspline catheter is the first single-shot PFA catheter approved for use in the European market. The most established single-shot technology for ablation of AF is the cryoballoon. To compare cost outcomes of the established cryoballoon system versus the PFA pentaspline in patients undergoing AF ablation from the English National Health Service (NHS) perspective. A cost-comparison was undertaken with a one-year time horizon for a population who underwent cryoballoon ablation for AF from April 2023 to March 2024 using Hospital Episode Statistics NHS Digital data. Patients could have an ablation with either the cryoballoon or PFA. Adverse events (AE), freedom from arrhythmia and repeat ablations were sourced from recently published comparative studies and the National Institute for Health and Care Excellence (NICE) AF guidelines (NG196). Unit costs were based on the NG196 and NHS reference costs (Table 1). The cost of the ablation procedure was calculated using the unit price for a day case from the 2024/25 NHS prices workbook, both with and without the cost of the catheters. Model input uncertainty was explored using deterministic sensitivity analysis. Over one year, treating patients with the cryoballoon catheter saved £144 per patient compared to the PFA pentaspline catheter, excluding catheter costs. Including catheter costs, savings increased to £1,885 per patient (Table 2). The primary driver in the base case was freedom from AF and fewer repeat ablations, as the group with higher AF freedom rate had lower costs related to repeat ablation. This was followed by AEs as the second key driver. When catheter costs were included, this became the main driver of savings. In all scenarios, cryoballoon ablation remained cost-saving (Table 2). The outcomes of the cost-comparison without the price of the catheters demonstrates that the established cryoballoon system remains a viable clinical and economic option, highlighting that its lower price is not the sole reason for considering cryoablation as a treatment compared to the PFA pentaspline. These financial benefits increased when catheter costs were included in the evaluation. Further evidence and economic analysis are needed to assess costs over a longer period and cost differences among the various PFA catheters available.Table 1.Clinical and Cost Inputs Table 2.Results

Pulsed field ablation (PFA) of atrial fibrillation (AF) using a pentaspline multi-electrode catheter is commonly performed under fluoroscopic guidance. No data exist on the integration of this catheter within a three-dimensional electroanatomical mapping (3D-EAM) system for left atrial voltage and activation mapping, posterior wall isolation (PWI), or redo ablation. To assess the feasibility of impedance-based mapping using the single-shot pentaspline PFA catheter itself within an open architectural EAM system, and identify advantages and limitations of this approach over fluoroscopy only. In this prospective series, impedance-based 3D-EAM within an open architectural EAM system was performed using the pentaspline PFA catheter itself. Cases involved real-time visualisation of the guidewire tip and PFA catheter within the 3D-EAM system. In certain cases, additional 3D-EAM was performed with a grid-style high-density mapping catheter for comparison. We studied 22 patients (45% female, mean age 63±13 years, 55% paroxysmal AF, 27% redo procedures). Five patients underwent concomitant high-density mapping, and six received PWI. Mapping increased procedural times (mean 108 mins, vs. 68 mins in fluoroscopy-only controls), without reducing fluoroscopy times. We identified three lessons: (1) The approach helped identify sleeves of incomplete pulmonary vein isolation (PVI) after index applications (Figure 1); (2) Mapping with the PFA catheter appeared concordant with the grid-style mapping catheter (Figure 2); (3) The technique facilitated robust PWI and helped identify inadvertent partial PWI. The cost-effectiveness of this approach requires formal assessment (additional equipment cost of £912 over fluoroscopy-only). 3D-EAM with a pentaspline PFA catheter is feasible, with potential advantages over fluoroscopic-only guidance or mapping with an additional high-density mapping catheter. This approach requires further workflow optimisation to minimise procedure duration, along with analysis of cost-effectiveness.Figure 1 Figure 2

Pulsed field ablation (PFA) of atrial fibrillation (AF) using a pentaspline multi-electrode catheter is commonly performed under fluoroscopic guidance. No data exist on the integration of this catheter within a three-dimensional electroanatomical mapping (3D-EAM) system for left atrial voltage and activation mapping, posterior wall isolation (PWI), or redo ablation. This technical report reviews an approach whereby mapping is performed using the pentaspline PFA catheter itself within an open architectural impedance–based 3D-EAM system. Cases involved mapping with the PFA catheter itself, with real-time visualisation of the guidewire tip and catheter within the 3D-EAM system. In certain cases, additional 3D-EAM was performed with a grid-style high-density mapping catheter for comparison. In a series of 22 patients (45

BACKGROUND With the exponential growth of catheter ablation for atrial fibrillation (AF), there is increasing interest in associated health care costs. Pulsed field ablation (PFA) using a single-shot pentaspline multielectrode catheter has been shown to be safe and effective for AF ablation, but its cost efficiency compared to conventional thermal ablation modalities (cryoballoon [CB] or radiofrequency [RF]) has not been evaluated. OBJECTIVE The purpose of this study was to compare cost, efficiency, effectiveness, and safety between PFA, CB, and RF for METHODS We studied 707 consecutive patients (PFA: 208 [46.0%]; CB: 325 [29.4%]; RF: 174 [24.6%]) undergoing first-time AF ablation. Individual procedural costs were calculated, including equipment, laboratory use, and hospital stay, and compared between ablation modalities, as were effectiveness and safety. RESULTS Skin-to-skin times and catheter laboratory times were significantly shorter with PFA (68 and 102 minutes, respectively) than with CB (91 and 122 minutes) and RF (89 and 123 minutes) (P < .001). General anesthesia use differed across modalities (PFA 100%; CB 10.2%; RF 61.5%) (P < .001). Major complications occurred in 1% of cases, with no significant differences between modalities. Shorter procedural times resulted in lower staffing and laboratory costs with PFA, but these savings were offset by substantially higher equipment costs, resulting in higher overall median costs with PFA (10,010) pound than with CB (8106) pound and RF CONCLUSION In this contemporary real-world study of the 3 major AF ablation modalities used concurrently, PFA had shorter skin-to-skin and catheter laboratory times than did CB and RF, with similarly low rates of complications. However, PFA procedures were considerably more expensive, largely because of higher equipment cost.

Symptom control for atrial fibrillation can be achieved by catheter ablation or drug therapy. We assessed the cost effectiveness of a novel streamlined atrial fibrillation cryoballoon ablation protocol (AVATAR) compared with optimised antiarrhythmic drug (AAD) therapy and a conventional catheter ablation protocol, from a UK National Health Service (NHS) perspective. Data from the AVATAR study were assessed to determine the cost effectiveness of the three protocols in a two-step process. In the first stage, statistical analysis of clinical efficacy outcomes was conducted considering either a three-way comparison (AVATAR vs. conventional ablation vs. optimised AAD therapies) or a two-way comparison (pooled ablation protocol data vs. optimised AAD therapies). In the second stage, models assessed the cost effectiveness of the protocols. Costs and some of the clinical inputs in the models were derived from within-trial cost analysis and published literature. The remaining inputs were derived from clinical experts. No significant differences between the ablation protocols were found for any of the clinical outcomes used in the model. Results of a within-trial cost analysis show that AVATAR is cost-saving (£1279 per patient) compared with the conventional ablation protocol. When compared with optimised AAD therapies, AVATAR (pooled conventional and AVATAR ablation protocols efficacy) was found to be more costly while offering improved clinical benefits. Over a lifetime time horizon, the incremental cost-effectiveness ratio of AVATAR was estimated as £21,046 per quality-adjusted life-year gained (95

BACKGROUND De fi ning postinfarct ventricular arrhythmic substrate is challenging with voltage mapping alone, though it may be improved in combination with an activation map. Omnipolar technology on the EnSite X system displays activation as vectors that can be superimposed onto a voltage map. OBJECTIVE The study sought to optimize voltage map settings during ventricular tachycardia (VT) ablation, adjusting them dynamically using omnipolar vectors. METHODS Consecutive patients undergoing substrate mapping were retrospectively studied. We categorized omnipolar vectors as uniform when pointing in one direction, or in disarray when pointing in multiple directions. We superimposed vectors onto voltage maps colored purple in tissue . 1.5 mV, and the voltage settings were adjusted so that uniform vectors appeared within purple voltages, a process termed dynamic voltage mapping (DVM). Vectors in disarray appeared within red -blue lower voltages. RESULTS A total of 17 substrate maps were studied in 14 patients (mean age 63 +/- 13 years; mean left ventricular ejection fraction 35 +/- 6%, median 4 [interquartile range 2-8.5] recent VT episodes). The DVM mean voltage threshold that differentiated tissue supporting uniform vectors from disarray was 0.27 mV, ranging between patients from 0.18 to 0.50 mV, with good interobserver agreement (median difference: 0.00 mV). We found that VT isthmus components, as well as sites of latest activation, isochronal crowding, and excellent pace maps colocated with tissue along the DVM border zone surrounding areas of disarray. CONCLUSION DVM, guided by areas of omnipolar vector disarray, allows for individualized postinfarct ventricular substrate characterization. Tissue bordering areas of disarray may harbor greater arrhythmogenic potential.

Aims Direct current cardioversion (DCCV) is a commonly utilized rhythm control technique for atrial fibrillation. Follow-up typically comprises a hospital visit for 12-lead electrocardiogram (ECG) two weeks post-DCCV. We report the feasibility, costs, and environmental benefit of remote photoplethysmography (PPG) monitoring as an alternative. Methods and results We retrospectively analysed DCCV cases at our centre from May 2020 to October 2022. Patients were stratified into those with remote PPG follow-up and those with traditional 12-lead ECG follow-up. Monitoring type was decided by the specialist nurse performing the DCCV at the time of the procedure after discussing with the patient and offering them both options if appropriate. Outcomes included the proportion of patients who underwent PPG monitoring, patient compliance and experience, and cost, travel, and environmental impact. Four hundred sixteen patients underwent 461 acutely successful DCCV procedures. Two hundred forty-six underwent PPG follow-up whilst 214 underwent ECG follow-up. Patient compliance was high (PPG 89.4% vs. ECG 89.8%; P > 0.999) and the majority of PPG users (90%) found the app easy to use. Sinus rhythm was maintained in 71.1% (PPG) and 64.7% (ECG) of patients (P = 0.161). Twenty-nine (11.8%) PPG patients subsequently required an ECG either due to non-compliance, technical failure, or inconclusive PPG readings. Despite this, mean healthcare costs (47.91 pound vs. 135 pound per patient; P < 0.001) and median cost to the patient (0 pound vs. 5.97; pound P < 0.001) were lower with PPG. Median travel time per patient (0 vs. 44 min; P < 0.001) and CO2 emissions (0 vs. 3.59 kg; P < 0.001) were also lower with PPG. No safety issues were identified. Conclusion Remote PPG monitoring is a viable method of assessing for arrhythmia recurrence post-DCCV. This approach may save patients significant travel time, reduce environmental CO2 emission, and be cost saving in a publicly-funded healthcare system.

Background Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Despite promising success rates, redo ablation is sometimes required. At redo, PVs may be found to be isolated (silent) or reconnected. We studied patients with silent vs reconnected PVs at redo and analysed associations with adverse outcomes. Methods Patients undergoing redo AF ablations between 2013 and 2019 at our institution were included and stratified into silent PVs or reconnected PVs. The primary outcome was a composite of further redo ablation, non-AF ablation, atrioventricular nodal ablation, and death. Secondary outcomes included arrhythmia recurrence. Results A total of 467 patients were included with mean 4.6 ± 1.7 years follow-up, of whom 48 (10.3%) had silent PVs. The silent PV group had had more often undergone >1 prior ablation (45.8% vs 9.8%; p <0.001), had more persistent AF (62.5% vs 41.1%; p =0.005) and had more non-PV ablation performed both at prior ablation procedures and at the analysed redo ablation. The primary outcome occurred more frequently in those with silent PVs (25% vs 13.8%; p =0.053). Arrhythmia recurrence was also more common in the silent PV group (66.7% vs 50.6%; p =0.047). After multivariable adjustment, female sex (aHR 2.35 [95% CI 2.35–3.96]; p =0.001) and ischaemic heart disease (aHR 3.21 [95% CI 1.56–6.62]; p =0.002) were independently associated with the primary outcome, and left atrial enlargement (aHR 1.58 [95% CI 1.20–2.08]; p =0.001) and >1 prior ablation (aHR 1.88 [95% CI 1.30–2.72]; p <0.001) were independently associated with arrhythmia recurrence. Whilst a finding of silent PVs was not itself significant after multivariable adjustment, this provides an easily assessable parameter at clinically indicated redo ablation which informs the clinician of the likelihood of a worse future prognosis. Conclusions Patients with silent PVs at redo AF ablation have worse clinical outcomes.

Introduction Three recent randomised controlled trials have demonstrated that pulmonary vein isolation as an initial rhythm control strategy with cryoablation reduces atrial arrhythmia recurrence in patients with symptomatic paroxysmal atrial fibrillation (PAF) compared with antiarrhythmic drug (AAD) therapy. The aim of this study was to evaluate the cost-effectiveness of first-line cryoablation compared with first-line AADs for treating symptomatic PAF in an English National Health Service (NHS) setting.Methods Individual patient-level data from 703 participants with PAF enrolled into Cryo-FIRST (Catheter Cryoablation Versus Antiarrhythmic Drug as First-Line Therapy of Paroxysmal Atrial Fibrillation), STOP AF First (Cryoballoon Catheter Ablation in an Antiarrhythmic Drug Naive Paroxysmal Atrial Fibrillation) and EARLY-AF (Early Aggressive Invasive Intervention for Atrial Fibrillation) were used to derive the parameters applied in the cost-effectiveness model (CEM). The CEM comprised a hybrid decision tree and Markov structure. The decision tree had a 1-year time horizon and was used to inform the initial health state allocation in the first cycle of the Markov model (40-year time horizon; 3-month cycle length). Health benefits were expressed in quality-adjusted life years (QALYs). Costs and benefits were discounted at 3.5% per year. Model outcomes were generated using probabilistic sensitivity analysis.Results The results estimated that cryoablation would yield more QALYs (+0.17) and higher costs (+£641) per patient over a lifetime than AADs. This produced an incremental cost-effectiveness ratio of £3783 per QALY gained. Independent of initial treatment, individuals were expected to receive ~1.2 ablations over a lifetime. There was a 45% relative reduction in time spent in AF health states for those initially treated with cryoablation.Discussion AF rhythm control with first-line cryoablation is cost effective compared with first-line AADs in an English NHS setting.

BACKGROUND Intracardiac echocardiography (ICE) represents a valuable image integration technique, with the unique advantage of dynamic real-time scar characterization. OBJECTIVES The goals of this study were to assess the correlation between ICE-defined and electroanatomic mapping (EAM)-defined scar in patients with ischemic cardiomyopathy and to define the outcomes of ICE-guided ventricular tachycardia (VT) ablation. METHODS Thirty-eight patients with ischemic cardiomyopathy (SOUNDSCAR cohort) underwent full left ventricular (LV) ICE imaging and EAM. ICE-defined scar parameters (end-diastolic and end-systolic wall diameter [EDWD and ESWD], end systolic wall thickening [percentage difference between EDWD and ESWD with respect to EDWD], slope [end-diastole to end-systole wall thickening], and American Heart Association wall motion scoring) were correlated with EAM-defined scar (voltage <1.5 mV). In a separate cohort (n = 21), outcomes of an ICE-guided VT ablation approach (EAM focused to ICE defined scar regions) were compared with those of conventional ablation (full left ventricular mapping with EAM only; n = 21). RESULTS In the 38 SOUNDSCAR patients (mean age 67 +/- 11 years; 35 male [92%]; left ventricular ejection fraction 31% +/- 10%; 2474 ICE segments; 524 ICE sectors), all ICE-defined parameters strongly predicted EAM-defined scar (area under the curve: American Heart Association score 0.873; ESWD 0.880; EDWD 0.827; slope 0.855; percentage difference between EDWD and ESWD with respect to EDWD, 0.851). All ICE-defined parameters had large effect sizes for predicting EAM-defined scar (logistic regression, P < .001). A detailed topographical comparison of ICE-defined (slope) and EAM-defined scar was possible in 25 patients and demonstrated 88% +/- 10% overlap. Compared with conventional VT ablation, ICE-guided ablation was associated with shorter procedure times and comparable VT-free survival (ICE-guided vs conventional: procedure time 240 +/- 20 minutes vs 298 +/- 39 minutes; P < .001; VT recurrence 3 [14%] vs 7 [31%]; P = .19). CONCLUSION ICE-defined scar demonstrates a strong correlation with EAM-defined scar. ICE-guided VT ablation is associated with enhanced procedural efficiency.

BACKGROUND AND AIMS:Methods for femoral venous haemostasis following electrophysiology (EP) procedures include manual compression (MC) and suture-based techniques such as a figure-of-eight suture secured with a hand-tied knot (Fo8HT) or a modified figure-of-eight suture secured with a 3-way stopcock (Fo8MOD). We hypothesised that short-term bleeding outcomes using the Fo8MOD approach would be superior to MC. We additionally compared outcomes between Fo8MOD and Fo8HT approaches. METHODS:We studied consecutive patients undergoing EP procedures at our institution between March and December 2023. Patients were categorised into three haemostasis groups: MC, Fo8HT and Fo8MOD. Access site complications were classified as major (requiring intervention or blood transfusion, delaying discharge or resulting in death) or minor (bleeding/haematoma requiring additional compression). RESULTS:1089 patients were included: MC 718 (65.9%); Fo8HT 105 (9.6%); Fo8MOD 266 (24.4%). Procedures were most commonly for atrial fibrillation (52.4%), atrial flutter (10.9%), and atrioventricular nodal re-entrant tachycardia (10.1%). In patients receiving periprocedural anticoagulation (865, 79.4%), Fo8MOD associated with fewer complications than MC or Fo8HT (major: MC 2.2%, Fo8HT 6.0%, Fo8MOD 0.8%, p = .01; minor: MC 16.5%, Fo8HT 12.0%, Fo8MOD 7.4%, p = .002). In patients not receiving periprocedural anticoagulation, complications did not differ between haemostasis methods (total major and minor complications 5.8%, p = .729 for between groups rates). On multivariable logistic regression, Fo8MOD was associated with a significantly lower risk of access site complications (OR 0.29 [95% CI 0.17-0.48], p < .001), whilst intraprocedural heparinisation (OR 5.25 [2.88-9.69], p < .001) and larger maximal sheath size (OR 1.06 [1.00-1.11], p = .04) were associated with a higher risk of complications. CONCLUSION:Femoral haemostasis with Fo8MOD associates with fewer access site complications than MC and Fo8HT following EP procedures that need periprocedural anticoagulation.

INTRODUCTION:Pulsed-field ablation (PFA) is a novel modality for pulmonary vein isolation in patients with atrial fibrillation (AF). We describe the initial uptake and experience of PFA using a pentaspline catheter across selected National Health Service England (NHSE) centres. METHODS:Data collected by NHSE Specialised Services Development Programme regarding AF ablation procedures using a single-shot, pentaspline, multielectrode PFA catheter (FARAWAVE, Boston Scientific) between June 2022 and August 2024 were aggregated and analysed to examine procedural metrics, acute efficacy and safety outcomes over 3-month follow-up. RESULTS:1034 procedures were submitted. The patients were 32.1% female, mean age 63.8±10.7 years, 53.1% paroxysmal AF and 89.7% first-time AF ablation. Procedures were performed by 48 consultant operators at nine NHSE centres, with a mean of 115 procedures per centre (range 25-264). 93.7% of procedures were performed under general anaesthesia. Median skin-to-skin procedure time was 74 min (IQR 55-96 min) and fluoroscopy time 20 min (IQR 15-27 min). Electroanatomical mapping was used in 15.3%. In first-time ablation cases, acute isolation of all pulmonary veins was achieved in 99.5% of patients. Left atrial (LA) posterior wall ablation using the PFA catheter was performed in 11.0% of cases; additional LA radiofrequency ablation was performed in 0.6%. The major and minor acute procedural complication rates were, respectively, 1.3% and 3.1%, with no reports of periprocedural death or atrio-oesophageal fistula. 63.8% of patients were discharged on the day of procedure. Follow-up data were available for 870 procedures (84.1%). In the 3 months following ablation, hospitalisation for arrhythmia occurred in 3.2%, with 0.9% rehospitalised for procedural-related complications. CONCLUSION:In this real-world, nationwide registry of a pentaspline PFA catheter, efficacy, safety and efficiency outcomes were comparable to those from previous PFA studies in patients with AF.